JONA
Volume 46, Number 9, pp 477-483
Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Nurses’ Perception of Shared
Decision-Making Processes
Quantifying a Shared Governance Culture
Sally O. Gerard, DNP, RN CDE, CNL
Deborah L. Owens, MSN, RN, NE-BC
Patricia Oliver, MS
OBJECTIVE: The aim of this study is to describe
how measuring the perceived and desired decision-
making capacity of nurses in a model of shared gov-
ernance (SG) can be beneficial.
BACKGROUND: Shared governance (SG) in-
creases nurse’s control over professional practice.
Engagement in SG can be impacted by how much
decision-making power nurses desire. This concept
related to decision making has been termed deci-
sional involvement (DI). Few studies exist that ex-
amine the concept of DI.
METHODS: Using the Decisional Involvement
Scale, acute care nurses were sampled concerning
desired and perceived decision making on 21 topics
related to nursing practice.
RESULTS: Analysis of the data identified different
governance priorities for several areas. Of particular
interest was that those nurses on SG councils for
more than 5 years did not report higher satisfaction
with decision involvement.
CONCLUSIONS: A comprehensive evaluation of
shared decision making was a valuable tool to estab-
lish a baseline of data and seek opportunities for im-
provement. A well-integrated model of SG requires
continuous improvement and analysis to be sustained.
Author Affiliations: Adjunct Professor (Dr Gerard), School
of Nursing, Fairfield University; Magnet Program Director
(Ms Owens), Magnet Program, St Vincent’s Medical Center, Bridge-
port; President (Ms Oliver), Pat Oliver Consulting, Newtown,
Connecticut.
The authors declare no conflicts of interest.
Correspondence: Dr Gerard, School of Nursing, Fairfield
University, 1073 N Benson Rd, Fairfield, CT 06824 (sgerard@
fairfield.edu).
DOI: 10.1097/NNA.0000000000000378
JONA  Vol. 46, No. 9  September 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Measuring and evaluating staff nurses desire to control
varied aspects of DI can allow organizations to make
focused efforts to strengthen SG.
Nurses play a vital role in today’s healthcare climate
of improving outcomes, the patient experience, cul-
ture change and transparency. Many positive influ-
ences have raised the level of the nurse’s involvement
in influencing healthcare. From the boardroom to the
bedside, nurses are taking leading roles to influence
the model of professional practice and the delivery of
care. Some nurses thrive in this environment, and
some struggle with the added responsibility that goes
far beyond delivering direct patient care.
One common model of supporting direct care
nurses in leadership is the concept of shared gover-
nance (SG), 1st reported in the 1980s. A variety of
influences have propelled SG into the forefront of
current nursing professional practice. Forces such as
the Institute of Medicine’s Future of Nursing Re-
port,1 the American Nurses Credentialing Center’s
Magnet Recognition Program ,2 and the vital role of
A
nursing in the redesign of healthcare have been influen-
tial. The complexity of today’s healthcare system
makes it vital that the largest discipline in healthcare
feel empowered to make decisions. A question that has
not been asked is, BHow much decision-making power
do staff nurses desire?[ The purpose of this article is to
describe how 1 organization quantified nurses’ perceived
and desired decision-making capacity and the relation-
ship to a model of SG. The analysis of survey data al-
lowed for valuable information specific to nursing units
and practice domains. This approach allowed nurse
leaders to formulate realistic action plans to support
477
specific areas of professional practice, which can be
difficult for the nursing workforce.
Background
Shared governance has been adopted by many
organizations as a vehicle to empower nurses.3 This
model of employee engagement increases nurse’s
control over their professional practice and is an
integral component for hospitals that have attained
Magnet designation. Shared governance provides
A
an opportunity to promote leadership of the direct
care nurse through involvement and control over
practice decisions.4 Models of professional practice
that increase decision making by nurses have been
empirically associated with better patient and nurs-
ing outcomes.5 Organization-wide councils specific
to nursing, such as research, professional practice,
quality, safety, and informatics, are commonly re-
ported.6 Some organizational models have intro-
duced councils on specific units to gain more clinical
nurse involvement. These unit practice councils
(UPCs) may be instituted simultaneously with the
larger councils or as a later development of a SG
structure. Communication structures for councils in
organizations vary, but many have a process of re-
porting up to some type of larger, organization-wide
council. The role of management with UPCs also
varies among organizations.7 The key to a SG model
is the active participation of direct care nurses and
the ability to make decisions about practice.6 But
how much decision-making capacity is too much?
The answer to this question may be key to taking an
organization’s SG structure to the next level by ex-
amining the concept of decisional involvement (DI).
DI of Nurses
Decisional involvement is defined as the pattern of
distribution of authority for decision and activities
that govern nursing practice policy and the practice
environment.5 The Decisional Involvement Scale
(DIS) has been published as a valid and reliable tool
that measures staff nurse DI within 6 constructs. The
6 areas include unit staffing, quality of professional
practice, professional recruitment, unit governance
and leadership, quality of support staff practice, and
collaboration activities.5 Within those 6 domains,
the tool measures the nurses’ perceived and desired
level of decision-making capacity.5 A unique feature
of the DIS is the ability to gauge the gap between
how much decision making nurses want and how
much they have. That gap in the perceived and de-
sired level of DI is referred to as dissonance.8 Disso-
nance is averaging the responsibility desired per
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
item and then subtracting the averaged responsibil-
ity that exists. It can be viewed as a measure if the
level of dissatisfaction with the current state.
A number of studies have used the DIS to study
issues of dissonance in nursing. Associations of DI
related to Magnet versus non-Magnet facilities, gov-
ernment versus nongovernment facilities, and in
relation to changes in an SG structure have been
studied.9-12 Only 1 publication studied nurses’ actual
and perceived DI at 2 separate intervals. A decrease
in the gap between actual and perceived DI was
found after the implementation of a new SG model.13
A few articles have linked nurse’s individual char-
acteristics (age, gender, years of experience, and hours
worked) to DI, with limited outcomes.9,12,14,15 Yurek
et al16 did find that the nursing practice environment,
strong relational coordination, and enhanced DI were
predictors of influencing work engagement. One of
the 1st studies to use the DIS tool reported a statis-
tically significant difference in nurse’s dissonance but
no correlation to educational preparation or years’
experience.9 These studies report interesting find-
ings on a broad perspective but do not provide nurse
leaders a data-based toolkit to address problems and
improve issues of dissonance.
Although the evidence regarding DI is relevant,
the results do not offer a direct connection with SG
involvement or tools for leaders to use in taking an
existing SG model to a higher level. The DIS explores
a range of topics, including nurses’ control over
scheduling to recommending disciplinary action for
peers. Clearly, these are topics in which nurses may
want different levels of DI. Having insight for specific
areas of governance that are causing dissonance
could be very valuable information for nurse leaders
in terms of support and mentoring.
The purposes of this study are to (1) report a
model to identify specific areas of DI contributing
to a gap in perceived versus desired decision mak-
ing (dissonance) and (2) investigate if there is a cor-
relation between involvement in SG councils and
dissonance among clinical nurses.
Setting
St. Vincent’s Medical Center is a 476-bed commu-
nity medical center in Fairfield County Connecticut
that has had an SG culture for 10 years. After the
initial implementation of an organizational nursing
council structure, UPCs were rolled out. The UPCs
regularly report activities to a coordinating leader-
ship council on a quarterly basis. St. Vincent’s Medical
Center attained Magnet designation in 2012. As a
Magnet-designated medical center with an SG struc-
ture, there was a desire to quantify the current culture
JONA  Vol. 46, No. 9  September 2016
around DI and develop a plan to continue to assess
the culture moving forward. To that point, the DIS
was used as a valid and reliable tool created for this
purpose.3,5
Method
Permission was obtained by the author to use the
DIS tool to gather data from direct care registered
nurses. The DIS consists of 21 items related to the
6 domains previously mentioned. Participants gave
feedback on each of the 21 items regarding how
much decision making they perceive they have for
that topic and how much decision making they
believe they should have.5,8 Anonymous surveys were
distributed on clinical units with return envelopes to
the project team. Results were collected for a 2-week
period. Returned surveys totaled 266 of approxi-
mately 776 clinical nurses, a 29% return rate. The
project was reviewed by the medical center’s institu-
tional review board and deemed exempt from
oversight. A statistician was brought it to the project
for analysis of data.
The DIS
The DIS is unique because it measures desired decision
making and perceived decision making. The survey is
composed of 21 topics, within 6 domains, related to
nursing practice.5 For each topic, the nurse has the
choice of the following decision-making authority:
1. Administration/management only
2. Primarily administration/managementVsome
staff nurses input
3. Equally shared by administration/management
and staff nurses
4. Primarily staff nursesVsome administration/
management
5. Staff nurses only5
The surveys included demographic informa-
tion, including years in nursing, years in organiza-
tion, work status (full-time, part-time, per diem),
participation in clinical advancement program (yes, no),
area of clinical work, actual unit, academic degree,
participation in council/committee within the last
5 years, and the number of current councils/committees
involved in (SG, UPC, clinician committees or other
nursing committees). The questions were formulated
to allow analysis of factors that might influence
score levels.
Results
After data cleaning there were 162 valid surveys
from 10 clinical areas. Most (72%) were full-time
JONA  Vol. 46, No. 9  September 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
nurses, and of that group, 64% had advanced in
the organization’s clinical advancement program.
In addition, 84% indicated that they did participate
in a hospital committee or UPC. When the score for
each participant was averaged across items, the scores
formed a normal distribution with a mean of 2.818
and standard deviation of 0.555. The scores ranged
from 1.00 to 4.555, with 68% of the scores between
2.263 and 3.373. Based on the purpose of the study,
the key measurement of the analysis was that of dis-
sonance. Dissonance, defined previously, is the gap in
the perceived and desired level of DI.8 In the analysis
of data, dissonance was calculated as the mathemat-
ical difference between who has decision-making power
on a specific topic and who study participants (staff
nurses) believe should have decision-making author-
ity for a specific topic. The level of dissonance was
measured by subtracting the individual scores of Bgroup
that makes decisions[ from the Bgroup that you believe
should make decisions[ scores and then averaged over
each item to find the dissonance per participant. For
example, nurses were asked to rate their perceptions
of who has greater decision-making authority over
selection of a unit leader and who they believe should
have authority over selection of a unit leader. The
overall dissonance in this topic was j1. This can be
compared with scores around decisional authority
of scheduling, which was j0.5. The scores indicate
where there some dissatisfaction with the status quo,
which is not unexpected. One key value in measur-
ing dissonance is to compare topics. In this example,
nurses were more satisfied their control over sched-
uling than in choosing the unit leader. The scores
were also averaged by topic to show the level of dis-
sonance per topic.
The survey uses a 5-point scale to indicate gra-
dations of responsibility for a particular item ranging
from 1, Badministration management only,[ to 5,
Bstaff nurse responsibility only.[ Dissonance is cal-
culated by subtracting the number associated with
the choice Bgroup that makes decisions[ from the
number associated with Bgroup that you believe should
make decisions[ for each item in the survey. This gives
the individual dissonance for each item. An average
dissonance score was then calculated for each partici-
pant. The scores were also averaged by item over
participant to show the level of dissonance per item.
In another approach to analysis of data, cumu-
lative scores of all respondents were assessed to
identify items with highest absolute values in average
scores, those items where there is greatest support for
SG and/or enhanced decision-making responsibility.
The 3 items that had the highest scores were sched-
uling and relations with physicians, including patient
care and development of practice standards. The
479

Figure 1. Levels of dissonance per professional domain.
lowest score per item was determining unit budget-
ary needs. Additional analysis grouped the questions
by the 6 domains (Figure 1). Based on that overall
analysis, staff felt the most satisfied with their DI in
unit staffing and least satisfied with their DI in
support staff practices. These larger concepts could
be studied by the organization as a whole or on the
specific units for themes of DI.
One thing to note is the direction of the DIS.
Given the survey language, a belief that manage-
Figure 2. Cumulative scores of desired decision making.
480
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ment has responsibility that should reside with staff
nursing will result in a negative score: 1 j 5 = j4.
The belief that staff nurses have responsibility for
something that should reside with management
would produce a positive score, 5 j 1 = 4. The
absolute value of the dissonance shows how far the
current state is from the desired responsibility level.
In this study, based on the negative values, it can be
assumed that nursing overall is looking for more
control over the varied topics. If an organization had
primarily positive numbers, one may assume that
nurses felt too much DI had been given to them.
Figure 2 displays the level of dissonance for
each item in the scale for the entire sample. Lower
scores indicate lower level of dissatisfaction, whereas
higher scores indicate higher levels of dissatisfaction
or dissonance. The greatest levels of dissonance (91
standard deviation from the mean) are for BSpecifica-
tion of number/type of support staff needed[ and
BReview of unit leader performance.[ On the other
extreme, the least amount of dissonance with regard
to the level of responsibility is in BRelation with
physicians re: patient care.[ Drill down with demo-
graphic data allowed for this type of analysis for
service lines and individual clinical units.
Factors Affecting Dissonance
Several independent-sample t tests and analyses
of variance found significance in several of the
JONA  Vol. 46, No. 9  September 2016
demographic areas (Table 1). Of particular interest to
the researches was the difference in scores of those
active in councils for more than 5 years. This group
did in fact have statistically greater levels of disso-
nance compared with those who had less longevity
in SG councils. There is statistically significant dif-
ference in the levels of dissonance between the dif-
ferent nurse statusVfull-time, part-time, and per diem.
As may be expected, per diem/casual status nurses
had the least amount of dissonance. Curiously, part-
time nurses had higher dissonance than full-time
nurses did.
Discussion
The literature in healthcare around DI is growing.
The DIS tool can be used in a variety of ways. The
cumulative findings of the study were interesting,
but the data were considered most useful when
studied by unit and by service line. Analysis of the
data previously described was able to identify dif-
ferent governance priorities for the individual units.
The summary of data by clinical unit indicated the
areas in which staff were most satisfied with (least
dissonance) and areas of decision making they were
least satisfied with (greatest dissonance). These data
specific to clinical units provide an opportunity for
leaders of UPCs, in collaboration with managers and
directors, to develop idea or opportunities around
specific topics.
To illustrate this, the specific data from the
oncology unit of this organization has been shared
(Figure 3). The level of dissonance for nurses on
this unit gives insight to specific areas they are
satisfied with. Staffing, which has been very high
on the cumulative list of priorities for staffing, had
a score of 0. This indicated that whatever the struc-
ture of the staffing is for that unit, it is meeting the
expectations of the staff in regard to DI. A key area
for oncology that staff nurses do not seemed satisfied
with is selection of new staff to work on the unit.
This is a topic that can be addressed with collabora-
tion of the leader and staff to involve others in the
selection process. Of note, 12 oncology nurses
participated in the study, which is more than 50%
of the total possible sample for this clinical unit.
Despite the fact that not all staff will normally par-
ticipate in voluntary survey, this type of data can pro-
vide valuable information for UPC, unit managers,
and organizational leaders. Annual evaluation of
DI can help continuously evaluate issues important
to staff.

Table 1. Level of Dissonance

Variable Level of Employment N Mean P

Status Full-time 117 j0.766 .044

Part-time 31 j0.879 .008
Per diem 10 j0.518
Clinical advancement Yes 103 j0.743 .920
No 47 j0.842 .896
2 2 j0.786
Clinical Area Medicine 45 j0.710 .904
Surgical 18 j0.632 .713
Perioperative 5 j1.448 .006
Critical care 21 j0.714 .899
Family birthing 14 j0.857 .369
Behavioral health 10 j1.405 .001
Oncology 12 j0.607 .650
Cardiology 7 j0.993 .202
Westport 10 j1.405
Other 28 j0.694
Degree Diploma 29 j0.893 .987
Associate 61 j0.746 .788
BSN 60 j0.719 .754
MSN 4 j1.250 .599
Other 3 j1.214 .667
AD 4 j0.536 .440
BA 1 j0.905
MA 0
Council participation Yes 123 j0.799 .425
No 39 j0.708
Council participation for 95 years Yes 136 j0.616 .028
No 11 j0.863

JONA  Vol. 46, No. 9  September 2016 481

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Figure 3. Dissonance levels for oncology unit.
The goals of this project were clear. Identifying
areas of dissonance collectively and for individual
units was evaluated. Implementing SG into the
culture takes time, resources, and continued sup-
port. How do we measure the success of SG and
UPCs? How strong are the staff nurses in a particular
area when it comes to assuming professional decision
making? How satisfied are empowered staff nurses?
The data available to organizations through the DIS
tool can quantify these questions and allow for
specific interventions of support. For example, an
ICU may have much lower dissonance scores in all
areas because the staff are more experienced and
autonomous. A medical unit may have higher dis-
sonance coming from particular domains yet the staff
nurses do not have the skill sets to address issues such
as budget decisions or providing input on unit
leadership concerns. The availability of data allows
for insights into specific areas for improvement in a
SG program.
The 2nd goal was to look for correlations in
SG council involvement and dissonance. The results
around this topic were surprising. Nurses involved
in committee work for a substantial amount of time
(95 years) had higher dissonance scores than did
those not involved in committee work or involved for
482
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
less than 5 years. In considering this outcome, the
project team hypothesized a variety of possible expla-
nations, including the following:
 Perhaps nurses who show a higher level of
dedication to an organization, as evidenced
by committee work for over 5 years, may have
a greater desire for change.
 Perhaps nurses involved in SG may require
education specific to enacting change and goal
setting for pursing change in large organiza-
tions that is not being offered.
 Council formats may need revision of pur-
pose and structure to allow participants to
feel more satisfaction.
Study outcomes were shared with councils and
nursing leaders. Although SG is an organizational
commitment, each unit or council has unique char-
acteristics and priorities. By providing clinical units
with feedback specific to their area, we allowed for
reflection and planning. Shared governance leaders
could review where their staff was in their journey
of decision making. The results of the study
allowed groups to evaluate areas where nurses are
most satisfied and least satisfied with unit empow-
erment models of SG. In 1 instance, a unit in which
JONA  Vol. 46, No. 9  September 2016
nurses showed high levels of dissonance around sched-
uling chose this topic as a priority for their UPC.
Implications for Nurse Leaders
Shared governance is an evolving process. It re-
quires continuous support and attention from nurse
leaders as issues and challenges evolve. Models of SG
can become stalled over time and need organization-
al support to move forward and be productive. The
culture of nursing professionals may vary greatly
among clinical units and leaders within the same
organization. Variation in nursing education, years
of experience, employment status, and experience
with councils can influence their desire to participate
in an SG model.9
Utilization of a valid and reliable tool that can
give insights into the perception of an SG model both
at the organizational and unit level can be valuable
for nurse leaders. An analysis similar to this study can
be easily conducted at identified intervals to monitor
effectiveness and change. Results of this type of can
also be provided to the UPCs to identify opportuni-
ties for growth in areas of dissonance. Limitations of
this study exist. A convenience sample of 1 medical
center makes generalization limited outside this
study. In addition, the small sample size of some clin-
ical units and self-report measure must be noted.
References
1. Institute of Medicine. The future of nursing: leading change,
advancing health. 2010. http://www.thefutureofnursing.org/
IOM-Report. Accessed November 13, 20 14.
2. American Nurses Credentialing Center. Magnet Recognition
ProgramA overview. http://www.nursecredentialing.org/
Magnet/ProgramOverview. Accessed December 1, 2014.
3. Barden A, Quinn Griffin M, Donahue M, Fitzpatrick J.
Shared governance and empowerment in registered nurses
working in a hospital setting. Nurs Adm Q. 2011;35(3):
212-218.
4. Kear M, Duncan P, Fansler J, Hunt K. Nursing shared
governance: leading a journey of excellence. J Nurs Adm. 2012;
42(6):315-317.
5. Havens DS, Vasey J. Measuring staff nurse decisional in-
volvement: the Decisional Involvement Scale. J Nurs Adm.
2003;33(6):331-335.
6. Fray B. Evaluating shared governance: measuring function-
ality of unit practice councils ant the point of care. Creative
Nurs. 2011;17(2):87-95.
7. Franklin B. Implementing unit practice councils. Nurs Manag.
2014;45(11):44-49.
8. Havens DS, Vasey J. The staff nurse Decisional Involvement
Scale: report of psychometric assessments. Nurs Res. 2005;
54(6):376-382.
9. Mangold K, Pearson K, Schmitz J, Scherb C, Specht J, Loes J.
Perceptions and characteristics of registered nurses’
JONA  Vol. 46, No. 9  September 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Conclusion
For this institution, a comprehensive evaluation of
shared decision making was a valuable tool to es-
tablish a baseline of data and seek opportunities for
improvement. Both cumulative and individual unit
data will be used as a benchmark as the study is
repeated at a 2-year interval. Nurse leaders and
nurses were able to have data specific for their area
and formulate strategies to reduce dissonance. Also,
areas were identified in which nurses do not desire
decision making and areas in which nurses were
satisfied with the current decision-making capacity.
By being able to narrow these opportunities, orga-
nizational leaders can target the most appropriate
plan for improvement, unique to the needs of clinical
units. Collaboration between nurses and a statisti-
cian for analysis and interpretation of the data was
valuable.
Shared governance is a complex dynamic frame-
work. Identifying objective data can provide an aware-
ness of where organizations are in the SG journey.
Nurse leaders can strive toward the goal of having
appropriate levels of decision making with the right
groups. A strong and sustained model of SG is reliant
on staff nurses comfort with decisional power and
leadership support. Collaboration with organiza-
tional leaders to continually assess and redirect SG
efforts can allow for maximum outcomes on all levels.
involvement in decision making. Nurs Adm Q. 2006;30(3):
266-272.
10. Myers M, Parchen D, Geraci M, Brenholtz R, Knisely-
Carrigan D, Hastings C. Using a shared governance structure
to evaluate the implementation of a new model of care. J Nurs
Adm. 2013;43(10):509-515.
11. Houston S, Leveille M, Luqire R. Decisional involvement in
Magnet, Magnet-aspiring, and non-Magnet hospitals. J Nurs
Adm. 2012;42(12):586-591.
12. Ahmed MZ, Safadi EG. Decisional involvement among
nurses: government versus private hospitals. Health Sci J.
2013;7(1):18-27.
13. Bina JS, Schomburg MK, Tippetts LA, Scherb JK,
Schwichtenberg TS. Decisional involvement: actual and
preferred involvement in decision-making among registered
nurses. West J Nurs Res. 2014;36(4):440-455.
14. Liu Y, Hsu H, Chen H. Staff nurse decisional involvement:
an Internet mixed-method study in Taiwan. J Nurs Manag.
2015;23:468Y478. doi:10.111/jonm.12154.
15. Ugur E, Scherb CA, Specht JK. Decisional involvement
among staff nurses based on educational level and certifica-
tion status. West J Nurs Res. 2015;37(5):619-633.
16. Yurek LA, Havens DS, Hays S, Hughes LC. Factorial validity
of the Decisional Involvement Scale as a measure of content
and context of nursing practice. Res Nurs Health. 2015;38:
403-416. doi:10.1002/nur.21668.
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